Recommendations for a Metropolitan COVID-19 Response

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GOAL OF THE METROPOLITAN STRATEGY

This strategy aims to slow transmission of the novel coronavirus and interrupt its spread. In metropolitan areas where cases are increasing, this strategy should delay and reduce the peak number of cases. In metropolitan areas where case numbers may be stable or declining, this strategy should accelerate the decline, creating more opportunities for decisions to relax social distancing policies.

The recommendations will require significant resources for implementation. Metropolitan areas should consider establishing public-private partnerships to coordinate and support this work.  

Recommendation 1

Convene an Expert Advisory Committee

The metropolitan area should create an expert advisory committee to include clinicians, health system representatives, epidemiologists, public health experts, and communications experts. The purpose of this advisory committee should be to review the latest developments and evidence and make recommendations to local leaders. The committee should meet at least weekly, with a defined agenda and specific questions for input to local officials.

Recommendation 2

Protect and Monitor Special Populations at Risk

Residents of long-term care facilities, nursing homes and group homes represent a major high-risk group for serious illness and death. Metropolitan areas should:

• Ensure that each facility in the area is aware of state and federal guidance for infection control through regular communication.
• Support and monitor compliance with guidance through on-site visits and collection of relevant data including policies for staff, number of staff calling in sick in the past week, current stocks of personal protection equipment, and daily visitor counts. To the extent possible, this reporting should be automated, such as through web-based reporting.
• Facilitate rapid response to symptoms compatible with COVID-19 infection, including testing (even in the context of limited availability of tests), isolation, and quarantine of close contacts. Consider developing teams that can rapidly respond on site to assess the situation and consider evacuating ill individuals from these locations to safe housing or hospital settings as appropriate.

Recommendation 3

Use a Call Center to Coordinate the Public Health Response and Provide Clinical and Social Support to People with symptoms of COVID-19

To decrease the number of infectious people transmitting COVID-19 to others and decongest clinics and hospitals, symptomatic patients should be screened to ensure they get the care and information they need. Contacts should be quarantined to reduce transmission to others. For this purpose, we recommend that metropolitan areas:

• Set up a call center to help people with COVID-19 compatible symptoms.
• Provide patients who have COVID-19 compatible symptoms with instructions to self-isolate and refer their contacts for quarantine.
• Trace contacts and inform them of their risk and need for quarantine.
• Schedule appointments for callers who meet testing criteria at their nearest testing sites.
• Facilitate referral of patients with severe COVID-19 compatible symptoms directly to the hospital or 911. Link patients with moderate or worsening symptoms to their physicians or to telemedical consultation accessible through the call center.
• Advise patients with mild symptoms who are isolated and contacts who are quarantined to monitor and report symptoms daily by entering data into a web- and/or text-based system that flags concerning entries for referral for additional public health action and/or clinical support.
• Use one highly publicized phone number but also take transfers from the city’s 311 or equivalent number. Provide an optional web-based interface for initial intake and triage to manage volume.

Recommendation 4

Establish Community-based Testing Sites

Testing should be made available, as much as possible, to help track where transmission is occurring and reinforce public health messages to isolate and quarantine.. Community sites are recommended to reduce patient flow to hospitals, keep infectious patients from seeking care at multiple primary care offices and from using public transport. Specifically, we recommend that metropolitan areas:

• Expand the availability and accessibility of testing in urban settings by providing community access to a basic COVID-19 specific health screening, testing, and links to social services to support isolation and quarantine for vulnerable communities.
• Select community sites for scheduled walk-up and drive-up community centers based on need, prioritizing patients based on risk of transmission and severe disease.
• Schedule appointments for patients at the community sites through the call center based on a telemedicine-based consultation that indicates they meet testing requirements and/or require in-person assessment of vital signs or oxygen saturation to determine the level of clinical support needed.
• Organize testing at community sites to minimize PPE and supply requirements, including asking patients to self-collect specimens when possible (as recommended by the CDC) and by adopting infrastructure to reduce the need for PPE.
• Use rapid and point of care tests at these community sites as soon as feasible.

Recommendation 5

Provide Social Services to People in Isolation and Quarantine and Others Adversely Affected by COVID-19 Control Measures

Isolation of infected patients and quarantine of their close contacts is the key to reducing transmission and slowing the spread of COVID-19. Whether based on test results or symptoms, people asked to self-isolate and close contacts asked to self-quarantine can only adhere to these recommendations if they have appropriate housing and sufficient food and medicine for the entire period of isolation/quarantine. Crucial public health messages can only have the desired impact on reducing transmission if support systems are in place to enable residents to comply with instructions. We recommend that metropolitan areas:

• Identify existing resources to assist people who need them with social services, including alternative housing, food, and medicine.
• Triage the need for these resources among people who are told to isolate or quarantine through the call center and community sites.
• Provide alternative housing for people with isolation or quarantine orders who are healthcare workers, homeless, in group housing, living with vulnerable people, or discharged from hospitals to any of the above circumstances before testing negative for COVID-19.
• Give home-bound individuals who need assistance a number (e.g., 211) they can call for help.
• Train call center phone operators and staff at community sites to link those in need to a case manager who can direct them to available resources.

Recommendation 6

Deliver Comprehensive, Informative Daily Messages to the Public

We recommend setting up ongoing and proactive communication channels to inform and advise the public about the outbreak. Accurate and up-to-date information should be provided daily via information sites and from local leaders. To do this we recommend that metropolitan areas:

• Deliver a daily data-driven press conference led by trusted sources like health officers and city leaders. Include in the briefing information about the outbreak, particularly local case and mortality information, local prevention recommendations and mandates for social distancing or staying home, and when and how to access testing and care.
• Coordinate with local community leaders to ensure these messages are amplified.
• Use all available communication channels to reinforce these messages including television, radio, and social media, as well as official websites and press releases.
• Target messages to specific audiences, including cases and contacts, high risk communities such as long term care facilities and group homes, and healthcare providers and hospitals
• Develop, employ, and regularly update channel-specific daily update templates to ensure that the most salient information is provided.

Recommendation 7

Use Data to Inform and Update the Response Strategy

• Integrate data systems to produce automated real time graphs, maps, charts, and tables in dashboards for use by health and city response teams and city leaders.
• Use evidence based on continuous analysis of data to inform updates to the strategy and plan so that it continues to meet the needs of the evolving situation.

AUTHORS

• Melissa A. Marx, PhD, MPH is an Assistant Professor in the International Health Department. She spent nearly 15 years practicing epidemiology including responding and leading responses to outbreaks for the CDC, first as an Epidemic Intelligence Officer, later as a senior epidemiologist for CDC at the New York City Department of Health and then for CDC overseas. She has responded to SARS, H1N1, Ebola and many other outbreaks.
• Emily Gurley, PhD, MPH is an Associate Scientist at JHSPH in the Epidemiology Department. Dr. Gurley spent 12 years at the International Center for Diarrheal Diseases Research, Bangladesh where she led the Surveillance and Outbreak Investigation Unit, and served as Director of the Program on Emerging Infections. She led investigations of outbreaks of Nipah virus, cholera, influenza, and anthrax, among others.
• Jennifer Nuzzo, DrPH, is an Associate Professor at JHSPH in the Department of Environmental Health and Engineering and is a Senior Scholar at the Johns Hopkins Center for Health Security. Dr. Nuzzo directs the Outbreak Observatory, which conducts operational research to improve outbreak preparedness and response.
• Lauren Sauer, MS, is the director of Operations in the Johns Hopkins Office of Critical Event Preparedness and Response and an Assistant Professor of Emergency Medicine at Johns Hopkins School of Medicine. She is the JHU focal point for their partnership with the WHO Global Outbreak and Alert Response Network. She has worked for almost two decades on healthcare system preparedness in disasters and outbreaks.
• Rupali J. Limaye, PhD, MPH is an Associate Scientist at JHSPH in the Department of International Health and also serves as the Associate Director for Behavioral Research at the Institute for Vaccine Safety and as the Prevention Core Manager for the Center for AIDS Research. She has a background in marketing and communication, and has developed health communication campaigns and materials in more than 20 countries.
• William Moss, MD, MPH, is a Professor at JHSPH in the Department of Epidemiology, Executive Director for the International Vaccine Access Center, and a Deputy Director at the Johns Hopkins Malaria Research Institute. He is a pediatrician with subspecialty training in infectious diseases.
• Justin Lessler, PhD, is an Associate Professor at JHSPH in the Department of Epidemiology researching the dynamics and control of infectious disease, with particular focus in the spread of pandemics. He develops and applies dynamic models and novel study designs to better understand and control infectious disease.
• Joshua Sharfstein, MD is a Professor of the Practice in Health Policy and Management, the Vice Dean of Public Health Practice. He previously served as secretary of the Maryland Department of Health and Mental Hygiene, the principal deputy commissioner of the U.S. Food and Drug Administration, and as commissioner of health for Baltimore City.

Supporting members: Molly Sauer (content), Diwakar Mohan (input), Alain Labrique (input), Smisha Agarwal (input), Forrest Jones (support), and Erica N. Rosser (support).

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• Guidance on Protecting Individuals Residing in Long-Term Care Facilities